Accident Overview
A single-engine aircraft departed Florianópolis on a cargo flight to Erexim with an intermediate stop in Blumenau. En route, the crew was informed that weather conditions had deteriorated in Blumenau, so the pilot decided to divert to Navegantes-Itajaí Airport. After landing, the crew was contacted by another company's crew who reported that weather at Blumenau Airport had improved. The aircraft subsequently departed for Blumenau.
While cruising at an altitude of 1,000 feet, the crew encountered poor visibility due to low stratus clouds. The aircraft struck the slope of a mountain located near Guabiruba, approximately 30 kilometers southeast of Blumenau Airport. Both pilots were killed.
Probable Cause Findings
The official investigation reported the following contributing factors:
- The flight schedule to which the crew members were subjected was contrary to Law 7.183 of 1984 and may have led to chronic fatigue and stress.
- Psychological variables at the organizational level, regarding flight scheduling, training, standardization, and procedures, contributed to the accident.
- Throughout the operation, both crew members showed signs of anxiety, complacency, underestimation of information, motivation issues, changes in perceptual synthesis, illusion, and inattention.
- Cloud base and visibility conditions made navigation and identification of ground control points difficult and prevented seeing obstacles.
- Insufficient planning led to the crew failing to navigate and fly themselves.
- The crew's failure to judge continued flight in adverse weather conditions below limits set by the Rules of the Air (IMA 100-12) contributed to the accident.
- Evidence indicated the company's involvement in not providing the crew with full technical conditions necessary for the flight.
- Failures suggested at least one crew member did not use available navigation resources and the other failed to advise.
- Visibility and ceiling conditions, along with the physical environment, influenced similarity between valleys of the Itajaí River and Itajaí Mirim. Conditions in the company's administrative-operational environment and pilot group contributed to difficulties.
- Errors imply supervisory failures in flight scheduling, training, and operations sectors regarding compliance with the law.
- The crew had little experience as pilots in the company and on the route flown.